Basic Information
| Provider Information | |||||||||
| NPI: | 1164539912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN HEALTH SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 MCKINLEY AVE | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087831267 | ||||||||
| FaxNumber: | 2087864471 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 MCKINLEY AVE | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087831267 | ||||||||
| FaxNumber: | 2087864471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 02/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | HALLER | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2087831267 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M8355 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002790500 | 05 | ID | MEDICAID | 000010006537 | 01 | ID | REGENCE | OTHER | CC9834 | 01 | ID | RAILROAD MEDICARE | OTHER | 8A570 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |